stigma

I’m going to try something a little different today. I’m posting a dictation between a patient of mine and me because I think it has flow and a nucleus. (There are a few small changes made in liberty, and no identifying data.) Let me know what you think of the content.

Psychiatrist: …And so we were talking about perfectionism, right?

Patient: Yes.

Psychiatrist: And about how you are not being kind to yourself when you expect yourself to be all healthy.

Patient: I’m not being kind to myself when I don’t want to take this or that because I don’t do synthetics. (This is what my patient was using to describe medications.)

Psychiatrist: I like that you used the word synthetics, because I’ve never put it in that perspective with patients, and you did that for me.

Patient: Well, there are non-synthetic and there are synthetic.

There’s body recognizing things, plants, and then there are the synthetics, what the pharmaceutical companies produce. And I’m a very negative pharmaceutical company person.

Psychiatrist: Compare that to other inconsistencies in our life. Such as, I’m going to be all-natural, I’m only going to wear hemp.

Or take it to the point where I’m going to weave my own clothes because it’s really natural and I know exactly what’s in it. Versus saying that I’m moving forward and I’m going to take what science has offered to us. I’m wearing polyester right now.

Or, I’m willing to take over the counter “herbs” because they don’t have the pharmaceutical stamp on it, or maybe I like that it grows out of the ground. But none of that has been governed. Aside from the “he-said-she-said evidence,” there’s often little science behind some popular over the counter remedies either.

Let’s consider that perhaps the study data, comparing in a regulated way, one patient with another, defined synthetic agents, and then allowed my body to be its healthier self. It gave us objective data. Numbers. Sure they have their flaws and weaknesses as we learn in statistics that all does. Poke holes in it as you wish, but at least there is a degree of transparency.

Patient: Maybe for me it’s more trust, because I feel like people are so over-medicated today. And it’s easy to write out a prescription than to really deal with the issue.

(Me, on the sly: This view, that practitioners prescribe for reasons other than for the medical benefit of the patient, is one that I honor with humility, and stand up and listen when others voice it. Annals fill the internet search engines on it, I’m sure. I will still pick at it a little, I’m a stubborn nubby person like that.

Let us note together that the word, “easy,” in this context isn’t so kind to our person. Taking medication to treat a medical illness is often not easy. It is one of the most courageous acts in someone’s life. And this wonderful lady, who came into my scary office, was a great example of this kind of courage. She wasn’t here doing what was easy. She was giving her emotional entrails a work-over with her psychiatry venture.

This patient, whom I will name hereafter, Lady Courage, was “really dealing” with the issue, in contrast to her self-described mores. Might we suspect the insidious tendrils of “Mister Stigma” shaming her? Yet here she was… Just fabulous!)

Lady Courage: I’m more one that, “Let’s really deal with your issues, and then your mind should come around, everything should come around.” That’s how I view it, because if you don’t fix the underlying problem you’re never going to fix the problem with meds.

Psychiatrist: Okay. But you’re willing to say there might be some inconsistencies in that right now.

Lady Courage: Right, no, I’m not …

Psychiatrist: It might not be entirely false, but it might not be entirely true.

Lady Courage: Exactly.

Psychiatrist: We were saying, “I can be healthy but still have disease in my life.”

Lady Courage: Yes, that’s true.

Psychiatrist: Because I don’t have to be perfect.

Lady Courage: Right. And I do find that a little bit hard. But since you put it in that aspect of being, “healthy with disease,” I can see that. I probably never saw that before, because I did always separate the two, either you’re one or the other.

Psychiatrist: Wow.

Lady Courage: Yeah.

Psychiatrist: That’s poignant. Is that how you see God as well?

Lady Courage: In what aspect? Like, yeah … Well, you know what? I try to strive to walk in His ways. I haven’t always walked in His way, so I do have guilt about that, but I shouldn’t have that and I know He’s already said He’s forgotten it, He’s washed me clean. So it’s just receiving it for myself. And that just is faith. And I know then it makes me feel like I’m lacking a little faith, but I know I should be stronger. But, yeah, The Word is something that I strive to follow, and it’s hard.

Psychiatrist: So do you feel like God is, “either/or,” in the way He looks at you? What about the parts of you that are diseased?

Lady Courage: Well, no, yeah, He’s going to heal that.

Psychiatrist: But what if He doesn’t right now? What does that mean about who God is?

Lady Courage: Well, He sent me here probably in hopes that you can help me to heal. He provides these avenues for us, so that we can get healed.

(Folks! So good! Smile.)

Psychiatrist: So you somehow think that God enters into the space of the synthetic.

Lady Courage: Well, yeah, I guess so, yeah. I do, okay. It’s so contradictory, but in one aspect I do take a thyroid medication that is a synthetic, but I know I have to take that and I understand it and I don’t feel it’s abusive. And I look at my blood work and I know where I’m supposed to be and how much I should be, so I feel confident. But when it comes to things like this that I’m not used to taking, and that don’t show up on labs, and it involves transforming my brain, I’m not really on board with that.

Psychiatrist: So when you use the word transforming my brain, I understand you’re saying that it’s making you into something different?

Lady Courage: It can alter your brain, yes.

Psychiatrist: Okay, so that’s the part I think that’s very scary for people, because they think it’s making them into somebody they’re not. But in reality the medications are there for healing who you already are. So for example, today you feel more like yourself than you did last week.

Lady Courage: Well, yeah, last week I was desperate and hurting and losing weight and scared.

Psychiatrist: And today you’re closer to who you think your healthy self is.

(Q: Closer to who God is creating you to be? Closer to God’s will even?)

Psychiatrist: In all of these scenarios, at each point we want to think, “What does this say about who God is?” If He or She, (but we will say He to simplify because it’s culturally appropriate,) is kind and loving like you mentioned, then would this belief, X, Y or Z, be true?

Self-Care Tip: Lay out our beliefs next to that standard, that premise in our life. And because we’re a lot crueler to ourselves, then we would allow other people to be, it can rescue us on occasion.

Like this:

I imagine some day I’ll understand why users think drugs are healthier options for them then medications.

“Doctor, I don’t think my wife will be comfortable with me adding another medication. It seems like I’m already taking so many!”

Context: Brennon is using THC “for sleep” he explains. Not recreation. It’s “medicinal.”

Boy. We are going to have to redefine what “medicinal” means in the urban dictionary vs. in the medical.

It’s as if the masses out there are acting like it is stigma behind any opposition of THC vs. science. Folks, there may be stigma involved but it’s mostly science. THC is, 99%, not medicinal.

My cousin is a hospice nurse and she and I were discussing this. Along the meandering conversation way, we came across, that in her field, many are taking CBD. (I know most of us think CBD is THC-free but it’s not unless it’s thoroughly governed by the FDA.) When we were in our wandering conversation about this, I imagined out loud to her, “If I were dying, I’d want to take a good trip on LSD, do a line of cocaine, and have free access to heroine. Why not?! “

My cousin politely explained that in end-of-life, most people, not apparently ignoramus blind bigots such as myself, prefer to stay alert in their last moments with their loved ones.

That makes a lot of sense. My “free ticket” to white clouded oblivion suddenly didn’t look as appealing. I’d like that too. I’d really like to have connection with my loved ones. At any time.

This is the effort in psychiatry as well, believe it or not. When we medicate, we are seeking to align ourselves with the patient’s agenda, toward connection and not away. Toward quality of life and not to harm. Toward hope. When we encourage to take medication, it is not to seek oblivion and isolation. Rather medication is for connection.

Brennon is not alone. Many think that medication takes us away from connection. Away from connection to ourselves by turning us into something we are not. “Doctor, I don’t want to take anything that will turn me into someone I’m not.”

Away from connection to God by taking our willingness to submit to His/Her will, away from His/Her power and toward depending on science instead, as if there is an either/or. No, there is no either-or unless we put it there. There are no dividers between science and God. He/She made them both. They are fluid to Him/Her.

Nor is taking medication taking us out of connection to our partners, nor our family who thinks medication is a cop out and whom are loaded with their own journey of self-discovery over their own self-stigma toward medication. As if taking medication makes our patients less loyal to their loved ones, thereby less connected.

It’s so layered why we think medication is worse. Even worse than mind-altering THC. Even worse, than the disabling illness, or whichever idea it may be.

Like this:

I’m sitting here in a volunteer medical clinic for a 60K attendee camporee. It’s humid and hot and we are seeing a lot of dehydration, amongst other things.

As a psychiatrist, I’m humming the Hallelujah chorus as I discover how much general medicine I still remember, from gout, viral rashes, respiratory and ear infections, cuts and bruises, and so forth. The group I came with teases me that if someone comes in for a cough, two hours later they will have disclosed that they were abused as a child and be swallowing prozac. I am ignoring this implication that I am missing “the point” by treating for psychiatric needs. Ignoring and missing, at least it’s consistent.

Our theme from this camporee week is appropriate. We have been looking at the life of David. In these, we see a whole lot of psychiatry going on, both medical/biological, and that which has to do with volition. King Saul demonstrated a sure biological mental illness. And David pretended to be crazy – call it, “acting out.”

God put this in the Bible for some reason(s). Question: What does this say about God’s character? I mean, we certainly don’t look up to people with acting out behavior, like David. Nor do we necessarily look up to people with mental illness like Saul, either. What does this say about who God is? Why does God put this in the Bible?

The Bible didn’t describe this as psychiatric, behavioral, acting out, or general medical. It just told the story. These ages later, we can do more with the story. Here in time, with the knowledge that the generations have given us, we could say something psychiatric was going on. But generally, despite this knowledge, we ignore the medical condition. We still talk about them with a weighted moral perspective, as if they departed from their spiritual walk in these behaviors, rather than consider the medical condition of their brains.

David is getting a javelin thrown at him while playing the harp. Patton State Hospital for the criminally insane might have housed king Saul if he were alive today. Then, David is in front of the Philistines with King Akesh, where he “pretended to be insane; and while he was in their hands he acted like a madman, making marks on the doors of the gate and letting saliva run down his beard.” (1Sam 21.)

Dr. Martorell, a neonatologist, told me,

“I see so many people afraid to discuss problems such as depression, anxiety, other psychiatric illnesses and even family problems or abuse. Yes, partly due to the fact that they may be judged as not having enough faith or not taking care of their health or not following certain principles.

Primary Care Nurse Practitioner Carrie stated,

“God and psychiatry go hand in hand I believe, but many Christians don’t think psychiatry has anywhere to go in the church. This is sad because my mom had bipolar, but nobody could help her. She needed the ‘extra help’. The church thinks we should be able to handle it ourselves.”

You may have seen the lock-down type who says, “Keep it in the family. Don’t tell others what goes on here. It’s none of their business.”

Dr. Martorell said,

Our cultural or family upbringing has a lot to do with how free we feel to discuss these issues. In certain cultures mental health problems are simply not discussed. If it gets brought up, the family directly or indirectly tells the affected person suffering not to discuss these outside the home, as though it were some dark secret that cannot be disclosed.

Nurse Carrie said,

“Everyone thinks we should deal with things on our own, and we shouldn’t have to talk to people about our problems and what’s going on in our lives.”

Ironically she is describing a condition of the church of independence. Yet inherent to being a believer is the learning to depend on someone else, God.

Nurse Carrie said,

“Why is it with depression and such, we can’t work as a church and have medical get it done.”

Many say, ‘If you go see a psychiatrist, it’s a sign of weakness. You’re not a good Christian.’ These are the comments I’ve heard of through the years. You should just pray, and God can take everything away.”

When my aunt suffered colon cancer, she didn’t get medical treatment in the beginning, preferring to have herself anointed, and follow a “homeopathic” approach. Later as it progressed, she changed her mind and found it was too late. So although largely, it isn’t only in psychiatry that we misrepresent who God is, we need ask ourselves, Who is God if what we believe about this is true?

Dr. Martorell shared,

As a neonatologist, I see infants born prematurely. Their brain develops outside the womb and are simply not the same as those that develop in a dark, quiet environment listening to mother’s heart rate, free of noxious/painful stimuli inside the womb. As much as we try to imitate a womb with our incubators we can’t provide the same care. When these infants are followed up for years, some develop physical deficits such as cerebral palsy, blindness, the need for oxygen, and the inability to eat on their own. These physical problems are easily seen and various treatments can be provided. They are also at greater risk for developing learning deficits, hyperactivity/inattention problems, depression, anxiety and some academic papers even suggest increased risk of schizophrenia. The thought behind these is that billions of synapses are occurring during pregnancy and the way these synapses connect is different in premature infants. It is also interesting to note that the brain volume preset at birth occurs during the last 4 week of pregnancy. As these children grow up they need treatment for physical problems as well as psychiatric problems they may develop.

I realize that it is not just in our churches that we are afraid to address this issue but I see it in the families of my newborns. So many of these moms self medicate with illicit substances in order to treat their anxiety or depression. Our culture as a whole has neglected to look at these issues as a medical problem that needs treatment. So many children and teens are committing suicide. Our own “well educated” health professionals have some of the highest suicide rates and yes it is occurring in our christian institutions as well as outside.

Nurse Carrie said,

“In this kind of approach, people are saying S/He’s not a loving and forgiving God and S/He doesn’t understand us. If you deal with psychiatry, you’re a sinner. Why can’t you get it done with God on your own. He’s not a loving God, saying this person is not allowed to take medication. The pastor’s describing a cruel God because he’s not allowing the person to get the help he needs. Like if someone’s leg is bleeding and you refuse to give that person a band-aid.

But, God is always loving. This can’t be true.

I don’t think the pastor has a right to tell the parishioner that.”

Maybe we just succumb to the awkwardness of it all. Too awkward to talk about God in our community. Too awkward to talk about psychiatry in our church. There are so many reasons we approach emotions and behaviors this way but in the church or outside of it, let’s consider the question, What does this ay about God’s character?

I was cleaning up a leg laceration about 1 1/2 inches long and 2cm deep. I placed the triple antibiotic ointment and approximated the edges with steri-strips, yet still encouraging the patient and her guardians to take her to the urgent care to get stitches. This wasn’t a sterile environment and our supplies were limited. While working on the wound of the young teen, I asked a few brief psychiatric intake questions. It turns out, no. She didn’t have anxiety, or depression, or psychosis. What do you know!? Not everyone does. But she and her guardians were super pleased to pray together before they left and I was blessed by them.

God is a God of love and the kind of God that cares about all of it in all of us. S/He is kind and not miserly, discriminatory, or punitive in interest and connection to us.

It sounds like from what i’m writing that psychiatry isn’t seen as a legitimate form of medicine in the church. Or maybe the church doesn’t refer to it, or support it.

A friend from my group read this post and responded.

“We hear a lot about emotions and behaviors in the church, and related directives. We don’t hear however about where emotions and behaviors come from.

I hear, ‘just pray more,’ or that I am lacking in faith. The people in the church get defensive, as if they have to defend God. And that’s not it. Honestly, it’s not complimentary to me that they think I’m insulting God. They are in a way attacking my spirituality. But I know God is helping me and He’s here with me. But I’m still this way. I still feel this way.

There’s a taboo that mental health and disorders all get grouped into this one cringeworthy word, “Crazy.” We’re almost protecting God from crazy by staying away from it in the church. We forget about the sin factor. The separation between us and God. The loss of connection. The word crazy isn’t very nice. So if we say crazy and we say psychiatry and God, it’s almost like we are besmirching God.

Self-Care tip: Ask, and ask again, What does “this” say about the character of God? It comes back to “Me.”

Question: Do see the Bible and your church talking about psychiatry? Where and how? What does it say about who God is?

Why do I feel so horrible when I start a treatment that is supposed to help?

Medication treatments for depression and anxiety, and some other brain illnesses, often worsen how you feel before you feel better. I can’t tell you how many patients have told me that if they had known this before, they never would have stopped their mediation(s).

Yesterday, our post discussed a Dr. Jones and Presley.

Presley fired Dr. Jones when after following her directive, he subsequently experienced an extreme panic attack. Dr. Jones may not have done anything wrong in her treatment recommendations. Presley was just an individual, as compared to a “number on the curve” of treatment responders. Escitalopram, the medication discussed as an example yesterday, (one medication option out of many), may have been dosed at an initial amount that Presley’s body couldn’t handle “straight out of the gait”, so to speak. But likely, if he had started at a lower dose, maybe ½ or even ¼ of the tablet, and then waited for his body to accommodate to the medication. Then Presley would have tolerated it. Presley would have tolerated slowly increasing the medication if approached, rather, piece-by-piece of a pill. I’ll even joke with patients,

I don’t care if you lick the pill. Just get on it.

When slowly titrating a medication, it allows the individual’s neurotransmitter receptors to down-regulate whilst the agent floods the receptors. If there is a neuron targeting another neuron, there’s a baseline balance in time. There is a baseline understanding between these neurons. An agreement, of sorts. “I’ll sit here and receive your messages,” (neurotransmitters, or chemical messengers such as serotonin, norepinephrine, and/or dopamine). “I’ll then carry those messages on your behalf to their intended recipients,” (such as the amygdala or hippocampus). But then this person artificially takes a higher quantity of these messengers, for example, by way of medications, and floods the system. The receivers, (or neuroreceptors), have to adjust to this to establish a new healthy baseline.

In this initial time of treatment, when 1st introduced to the increased neurotransmitter-load, (ex: as released by a tablet of Escitalopram), there can be a negative response, such as panic and/or depression emotions. We call this, “initiation side effect’s.” Once the neuroreceptors get used to the new load, then the response improves.

After accommodating to the new pharmacology, the brain is allowed to experience the blessing that comes from treatments, and heal.

Some individuals are outside of the curve and cannot tolerate the standard initial treatment dosage, like Presley was. Some are inside, and can without much difficulty. The point in treatment, though, is that the person just needs to get on it.

Get on treatment. However you do it. You have to make the treatment work for you, an individual, in your own way. The prescriptions are there to serve you. You aren’t there to serve the medications. I like to analogize Jesus’ statement,

The Sabbath is there for man, not man for the Sabbath.

Make it yours as an individual and reap the benefits; the blessings inherent there. (See Mark 2:27).

If you don’t get on the treatment, you won’t get better. Anything less than this will be inadequate. It’s like drying water off your face with a hand towel while still walking in a rainstorm.

What is your agenda in treatment? List it. Write it out. Then, go get you some!

Outside a medical approach is like flicking water off in the context of a rainstorm. If your agenda is getting to your healthy self. Get out of the storm and get dry. Then go get it.

You have a medical condition. Treat it with the assistance of a medical professional.

I don’t go to a plumber to help with my electrical home repair. I don’t go to an accountant or a church counselor to treat a medical one.

The plumber, the accountant, the church counselor are what they are.This is not minimizing their efficiency in their own fields of excellence. But why do we seek care in psychiatry from those who haven’t studied this? From those who are not experts in this? Maybe stigma keeps us away from psychiatric care. Maybe misinformation directs our search for mental health treatment elsewhere.

Self-Care Tip: Get you some medical therapy for medical illness.

Question: What are further concerns you may have about taking medications? How would you prefer your medical providers to work with you? Please tell us your story.

Presley couldn’t breath. A truck just drove through his thorax. A monster-hand was closing around his heart. He couldn’t swallow well. Was something stuck in there? Dizziness nearly dropped him, but instead of moving to sit down, like any other normal person would do, he bolted. A fire chased him. He had to escape or he would die. In the bathroom where he found himself, the mirror reflected a sweaty face and crazy eyes. Was he dying? Presley’s phone looked blurry as he dialed, 911.

Please help! I’m having a heart attack!

That was the first time this had happened. After the third visit to the emergency room over the past month, Presley was able to avoid calling 911, although still convinced he was going to die when the next episode hit. He agreed to seek counseling, where he was taught different skills to connect his mind and body, to slow his breathing down, to process, even when he was convinced he was dying. For a time, Presley improved. It was like it never happened. He was almost able to convince himself that it wouldn’t happen again.

This turned over and over, feeling like he was going to die while losing his mind, re-engaging in counseling, thinking he was better, stopping counseling, and then another violent emotional event, thinking for sure, he would die.

It was after his second trip to the ER when he received the recommendation to schedule an evaluation with a psychiatrist. But he preferred to work through this in therapy. Presley didn’t like pills. He wasn’t someone who medicated. An olive-skinned athlete, he lived clean and didn’t believe there was much that healthy living couldn’t cure. And Presley did live clean. He ran fifty miles a week. He ate raw foods. He read his Bible.

After several months of this, his therapist, Dr. Wu, recommended he get a psychiatric evaluation. However, Dr. Wu agreed that he would continue to work with him, whatever Presley chose. (Was this the right thing for Dr Wu to do?) Presley chose, no. No psychiatrist. What would a psychiatrist do to him anyway?! He wasn’t crazy. (Except when he thought he was.)

Presley visited his primary medical physician, Dr. Belinda Jones. It had to be better than seeing a shrink!

Dr. Jones, I don’t want to take meds.

Dr. Jones, cleared him for any medical condition that might be contributing to his events. Only then was she able to convince him to try a “safe antidepressant”, escitalopram. After one pill, Presley had the worst event of his life. He’d never had any experience that was more terrifying. Presley didn’t go back to Dr. Jones, “of course.”

When these emotional tornadoes hit more frequently, he became paralyzed with fear that he would have them in public and be humiliated by them. Presley stopped going to work. If it wasn’t for his rent, he’d never go back. But he had to. So finally Presley agreed to see a psychiatrist. …

To be continued

Sincerely, Dr. Q

Questions: What would you tell Presley?

How would you like your physician and/or therapist to handle this, if it were you?

“We know the Bible speaks of sins of the fathers passing to the 3rd and 4th generations while God imbues his kindness and mercy far beyond that to those who love him and keep his commandments.”

Rosa had no experience in the world of mental health, or so she thought. She had spent her formative years studying the world through the perspective of her church and interpretations of the Bible. As you know, there is a lot in both with a lot to say about emotions and behaviors. However Rosa was taught and modelled that these were moral issues and not biological. An either or, verses, part of the same thing. Could we call it sequent variants, maybe something like genetic alleles? Or maybe something better to describe this is out there, rather than an either or.

Rosa Leticia Montoya, at this point in her development, with her own overwhelming emotions and her husband’s plummet into dark moods, felt forced into considering mental health. She did not want to go there, but here in the space of losing control, not trusting herself or Carl any more, and before she was willing to say she didn’t trust God, she was doing what was a last resort. Considering that she was going crazy was the only thing this chaos could mean.

Before she completely surrendered to the idea that biology was behind this sinister change, she had to ask, “Is this because of our parents?” She had spent her life trying to untwist the bad choices her parents had made and the consequences those choices had on her life. Drugs, alcohol, and cheating were what she had grown up with. Quietly. Hiding it in the church. Rosa there, praying a lot to live well and be forgiven. Praying that bad thoughts would go away. Praying to depend on God and not on herself, as seen through her perseverating worries ever since she was a child. Worried and worried. Not speaking of the wrong Bible-breaking life her parents wore like underwear beneath nice tailored clothes. Would she ever be forgiven? Would she ever stop sinning?

So she asked me, “What do you think?”

That’s a lot to work with as a psychiatrist. So I did what most of us do. Ran to the shelter of medicine. Whew! But there is the added benefit that God created medicine, psychiatry, and all that there is in my tool bag worth working with.

Even so, there was only so long that I could avoid the topic of God and His punishments, per her perspective. It came up every visit.

If you believe in God, at some point within your discovery of mental health, this question will come up. Rosa is not alone. Are the emotions and behaviors gone amok, such as seen in anxiety disorders and depression, secondary to moral weakness? Living with “too little” dependence on God’s power? Is it this? Or is it an “either or”, with our biology? …a matter of cellular grey matter composed of DNA-expressing pathology? And is this something evil woven into my DNA because of what parents did? Well, I’ve spent 30-some years in school and now 15+ years in practice in this space and am still trying to understand.

I’m wondering if you would help me articulate this. It’s fundamental for us in self-care. It’s not possible to be very friendly to ourselves with the dissonance.

So in our self-care question today, please answer us. What is the relationship between “the sins of the fathers” and biology? Please speak!

In an interview with Kitty and Michael Dukakis, journalist Katia Hauser explores the benefits and risks of electroconvulsive therapy (ECT) in treating depression. Kitty shares her first hand experience with ECT and the ways it changed her life, and Michael provides the perspective of a family member.